Costs for Long-Term Health Care After a Police Shooting in Ontario, Canada

This cohort study examines follow-up data for adults injured by police to analyze long-term health care costs among survivors of police shootings compared with those surviving nonfirearm police enforcement injuries.


Introduction
Police shootings are defined as injuries involving a firearm discharge by law enforcement agents while on duty. 1 Police shootings often reflect split-second decisions, lead to about a thousand deaths in the United States annually, and garner extensive public media attention through local and national reporting. 2,3However, most police enforcement injuries do not involve a firearm and do not cause death. 4,5[8][9]

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Public discourse around police shootings sometimes neglects the extended aftermath.First, most police shootings are not fatal, and death counts alone underestimate the extent of personal losses. 10Second, modern acute care is increasingly effective, so declining mortality trends might not mirror the collective burden of losses. 11Third, the extent of injury is not always initially apparent. 12urth, other mechanisms of police enforcement are not always innocuous. 13,146][17] Sixth, the larger goal of restoring productive members to society requires many personal, medical, and social resources. 18e mean cost of acute care for a patient with a gun injury in Canada is about CAD$32 203 (US $17 593) from emergency transport, initial resuscitation, and critical care. 8,19However, long-term costs are substantially larger and include lost employment, personal damages, and other intangible effects. 20For police shootings, little is known about the long-term economic and health outcomes for survivors.The purpose of this study was to evaluate the long-term health care costs and disability for adults surviving a police shooting.

Setting
Ontario is Canada's most populous province and accounts for the most police shootings in the country. 21,22The mean health care cost is CAD$4883 (US $3609) per person annually.[25] Prevailing laws during the study mandated medical reporting of all patients with a gun injury. 26ergency care was universally available, publicly funded by the Ontario Health Insurance Plan (OHIP), and tracked through encrypted linked records after a lag for data security and collection. 27,28[31][32][33] The study protocol covering privacy, security, and ethics was approved by the Sunnybrook Research Ethics Board, including a waiver for direct patient consent.The study was also approved by ICES with standard privacy and security safeguards.The use of the data in this project was authorized under section 45 of Ontario's Personal Health Information Protection Act.The study design and reporting followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline and ICES standards. 34

Police Shootings
We identified consecutive adults (age Ն16 years) injured in a police shooting who received emergency care between April 1, 2002, and March 31, 2022.Past reports established that available databases were comprehensive (covering >99% of emergency departments), connected (linkage rates >95%), and consistent (diagnostic reliability >90% compared with medical record abstraction). 29,35,368][39][40][41][42] We excluded patients who died at the scene, those living outside Ontario, individuals lacking a valid health card number, and youth younger than 16 years.
Patients with more than 1 incident were analyzed by the first presentation to avoid statistical artifacts from double counting due to trauma recidivism (eFigure in Supplement 1). 43agnostic codes identified injuries from police enforcement as diagnosed by clinicians.We defined a police shooting as an injury "caused by legal intervention involving a firearm discharge" (code Y35.0).This included revolvers, rifles, rubber bullet weapons, machine guns, or other firearm types.We defined control injuries as those caused by other forms of police enforcement that also required emergency care.This included incidents involving batons, staves, blunt objects, manhandling, tear gas, electricity, asphyxiation, explosives, bayonets, or unspecified means (codes Y35.1 to Y35.99).A limitation of this approach was the lack of data on injuries indirectly related to

Additional Characteristics
Data on patient age (years), socioeconomic status (quintile), sex (binary), and home (urban, rural) were based on linked demographic databases. 44,45Additional health care records identified the incident time (day and hour). 46Uncertain cases were classified as nonfirearm injuries so that no patient was excluded from analysis.Additionally, we identified psychiatric illnesses and substance use disorders in the year before the injury from linked outpatient medical records. 47,48We obtained additional indicators of overall utilization in the year before injury to calculate baseline health care costs (hospital, emergency, outpatient). 49Information on crime records, educational attainment, ethnic background, adverse childhood experiences, and military service was not available.

Acute Care
We examined short-term acute care clinical outcomes for context and comparison with past research from other regions.

Subsequent Disability
Chronic disability was defined by the formal submission of a disability support application as determined using official social service records (OHIP codes K050-K054). 52Long-term disability support applications in this setting required a medical report by a responsible physician (Health Status Report, Activities of Daily Living Index, Special Necessities Benefit Form). 53An application reflected the patient's perception of disability and required physician authentication.This methodology has been validated in past research and may underestimate the burden of disability. 54 considered death as a competing outcome for analysis of long-term disability.The available databases did not contain information on the specific nature of the disability, whether a formal application was rejected, or how a disability connected to the original injury.

Primary Outcome
We applied the ICES long-term costing algorithm to estimate the total direct annual costs of health care following the initial injury adjusting for inflation (reference year 2021). 55,568][59][60][61] For the cost analysis, we restricted the analysis to complete cases with at least 5 years of available follow-up data (even if some intervals involved zero costs).Each analysis was concluded at 5 years to minimize biases from uneven durations of longer patient follow-up.These restrictions allowed economic estimates to provide unbiased analyses of annual costs over a 5-year longitudinal follow-up (yet underestimated the total lifetime costs of injury).Two further assumptions were that medication costs were not included (not consistently available) and ancillary costs from insurance, unemployment, bankruptcy, or incarceration could not be evaluated (also unavailable).Costs were expressed in prevailing Canadian dollars and may differ from US charges. 62

Specific Cost Components
Health care costs were estimated by combining institutional expenses, physician payments, and miscellaneous services.Institutional expenses included mental health services, medical care, surgical procedures, rehabilitation treatment, chronic care, outpatient clinic, and same-day surgery costs.

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Long Physician payments were based on the prevailing payment schedule and included general fee-forservice, specialist fee-for-service, and physicians practicing in prisons. 56,63Miscellaneous services included home care service, emergency visits, and outpatient miscellaneous costs.Nonphysician emergency department costs were estimated according to Comprehensive Ambulatory Classification Systems groups. 64[67][68]

Statistical Analysis
The primary analysis tested whether annual health care costs were higher for patients after police shootings compared with control patients injured by other mechanisms involving police enforcement.The follow-up interval began on the day of hospital discharge, excluded patients who did not survive initial injury, and examined a time horizon of 5 years (expressed as annual costs).We also used a self-matched design to evaluate annual costs for each patient before and after injury (identifying each person as their own control and quantifying relative cost ratios with corresponding geometric means).Secondary analyses evaluated rates of acute mortality (unadjusted cumulative incidence computed using logistic regression to analyze death rates) and rates of disability (using the Fine and Gray model for subdistributional hazard ratios).No data imputation methods were used.
Additional analyses were conducted for descriptive and exploratory purposes.We profiled baseline demographic and medical characteristics for the 2 groups to assess differences between patients injured by police shootings vs those with control injuries (eTable 1 in Supplement 1).We examined basic elements of acute treatment to profile initial medical care.We used multivariable regression models to explore additional independent correlates of long-term health care costs.We unbundled subsequent expenditures by category to identify the major contributors to long-term health care costs.

Results
A total of 13 545 adults were injured by police enforcement during the 20-year study, a mean of 2 individuals per day.The typical patient in each group was a man younger than 40 years who was living in a city at or below the middle socioeconomic level (Table 1).Few patients were injured by police shootings (n = 178) and most patients by other mechanisms (n = 13 367).Those injured by police shootings were relatively more likely to be male, living in a rural region, and previously diagnosed with a mental health condition.Mean (SD) health care costs for a patient during the year before injury showed no significant difference between the 2 groups (CAD$5384 [10 094] vs CAD$5179 [15 457]; US $3976 [7455] vs $3825 [11 416]; P = .77).

Acute Care
The profile of acute care emergency treatment suggested greater injury severity for patients after a police shooting relative to controls.This discrepancy included a higher frequency of ambulance involvement, hospital admission, surgical procedures, critical care admissions, and blood product transfusions (Table 2).The mean (SD) hospital length of stay was 1 week longer for patients after a police shooting relative to controls (13.5 [18] days vs 5.8 [9] days, respectively; P < .001).A total of 25 patients died during initial hospitalization, with higher mortality for patients after a police shooting relative to controls (16 [9.0%] vs 9 [0.1%], respectively; P < .001).The remaining 162 patients with firearm injuries and 13 358 patients with control injuries survived the initial hospitalization.

Chronic Disability
The 13 520 total survivors accounted for 52 102 patient-years of follow-up (mean, 3.85 years).
Patients surviving a police shooting accounted for 28 subsequent cases of disability over 525 patient-

Subsequent Health Care Costs
Long-term costs totaled CAD$241 675 273 (US $178 491 690) among the 8755 long-term survivors who had 5 years of follow-up data available (eTable 2 in Supplement 1).Patients surviving a police  (Table 3).The next largest contributors were outpatient clinics and home care services.The difference in total costs was not explained by surgical inpatient care, emergency visits, or outpatient physician services.If patients who survived a police shooting had costs that instead followed the patterns of those for control patients, we estimated a potential savings of CAD $1.88 million (US $1.39 million) in health care costs.

Associations With Long-Term Health Care Costs
Supplementary analyses of long-term survivors examined additional characteristics associated with increased health care costs after surviving acute injury.Older age, weekday timing for the incident, and prior health care costs were each associated with higher long-term health care costs (Table 4).A past diagnosis of mental illness or substance misuse was also associated with higher long-term costs

Discussion
We studied data for more than a hundred patients injured from a police shooting and thousands injured from other mechanisms by police enforcement.We found a 3-fold increase in long-term health care costs among those surviving a police shooting relative to controls.The absolute increase in long-term health care costs were substantial, a mean of nearly CAD$10 000 per patient annually for those who survived a police shooting.The increased long-term costs were not explained by demographic characteristics and mostly related to psychiatric care services (with modest differences in other medical care).Together, the findings suggest that police shootings have associations with acute mortality, emergency resuscitation, and long-term health care costs.b No adjustment for baseline differences.
c Adjusted for all measures in univariable analysis.

Past Research
Our results support findings from other settings examining police shootings.Studies from the United States suggest that 99% of police-related injuries are not from firearms. 69We also found an overrepresentation of young men of lower socioeconomic status living in cities, in accord with other research. 70Additionally, we demonstrated high rates of acute mortality, critical care, blood transfusions, and surgical procedures after police shootings comparable with reports from diverse contexts. 71,72Our finding of a significant increase in psychiatric care after a shooting corroborates past research on individuals experiencing nonfatal shooting assault. 73In line with qualitative research, we found substantial delayed consequences, including ongoing health care costs and longterm disability. 74,75Consistent with social science descriptions, we found extensive psychiatric burden for patients who survive a police shooting.
Several reasons might explain why police shootings are associated with substantial long-term health care costs.Psychological theories of trauma-induced disability emphasize a progression after physical injury with initial helplessness followed by chronic maladjustment. 779][80] Compared with other forms of enforcement, police shootings may exacerbate depression (two-thirds of patients) and posttraumatic stress (half of patients). 81,82ychiatry research involving military combatants suggests early therapy may prevent the emergence of mental illness after gunshot injuries.Randomized clinical trials show that antidepressants may mitigate the emergence of posttraumatic stress disorder in some patients (eg, sertraline, 50 mg once daily). 83α-Blockers might potentially lessen nightmares in patients after traumatic exposure (eg, prazosin, 10 mg at bedtime). 846][87] Together, evidence from military medicine suggests early intervention could potentially mitigate mental illness in survivors of police shootings. 88

Future Directions
Additional research could further explore how police shootings are associated with long-term health care costs.An incipient mental health crisis could have provoked reactive police enforcement in the first place, although we found no corresponding imbalance in mental health diagnosis prior to injury. 89,90Mistrust of medical institutions might also be common after police shootings and may lead to delays in preventive care or unchecked accumulating morbidity in survivors. 74,75,91Death anxiety may develop, whereby survivors become constantly fearful of further disability and exhibit excessive care-seeking. 793][94] Specific psychiatric interventions also need to be directly tested in this setting to assess effectiveness and safety.In addition, more complicated econometric modeling with data imputation might be considered for testing repeated events or cases with partial follow-up intervals.
Chronic pain may lead to prolonged reliance on analgesics or substance use disorders. 95These adverse sequelae and risks of recurrence are opportunities for future research.

Findings
When compared with other mechanisms of injury involving police, are police shootings associated with greater long-term health care costs?In this population-based cohort study with data for 13 545 adults injured from police intervention, there was a 3-fold increase in long-term annual health care costs for patients surviving a police shooting compared with other mechanisms of injury.Most of the increased costs were due to psychiatric care.Meaning This study found a substantial increase in the health care costs in the years after a police shooting, thereby highlighting the need for early multimodal interventions.

Figure
Figure.Risk of Long-Term Disability

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enforcement such as a traffic crash after a police chase.A further limitation is that each of the 2 groups had diverse types of injuries because of the range of potential mechanisms.
a Mechanism of injury was rifle, revolver, machine gun, or other firearm discharge.bd Based on home neighborhood.eOntario Health Insurance Plan diagnostic codes 290 to 316 (except 293, 294, 303, 304, 308, 310, 312).fOntario Health Insurance Plan diagnostic codes 303 to 304.g Canadian dollars adjusted to 2021.shooting

Table 2 .
Acute Care Medical Treatments a Based on packed red cells, platelets, or whole blood.bIncludes emergency or hospital and excludes deaths at the scene.